1790707842 NPI number — TARA ALEXANDRA MCCANNEL MD

Table of content: TARA ALEXANDRA MCCANNEL MD (NPI 1790707842)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790707842 NPI number — TARA ALEXANDRA MCCANNEL MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCANNEL
Provider First Name:
TARA
Provider Middle Name:
ALEXANDRA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
YOUNG
Provider Other First Name:
TARA
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1790707842
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/07/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5767 W CENTURY BLVD
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90045-5631
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-825-5000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 STEIN PLAZA
Provider Second Line Business Practice Location Address:
RM 1-340
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90095-7065
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-825-5000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/24/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  A87675 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 00A876750 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".